© 2003 American Thoracic Society
"What We've Got Here Is a Failure to Communicate"Boston University School of Medicine, Boston, Massachusetts Correspondence and requests for reprints should be addressed to Jerome S. Brody, M.D., Professor of Medicine, Director, Pulmonary Center, Boston University School of Medicine, 715 Albany Street, Boston, MA 02118. E-mail: jbrody{at}bu.edu The May 1 issue of the AJRCCM (the Blue Journal) (pp. 1176–1180) published the results of a survey of American Thoracic Society members that provides important demographics about the society and an insight into how various American Thoracic Society programs are valued by its members (1). The survey is accompanied by an editorial written by Macklem (2) that focuses on the low rating of the AJRCMB (the Red Journal) by responders. Macklem poses the provocative question "Is cell and molecular biology divorcing from clinical practice?" Dr. Macklem suggests that today's basic science and basic scientists have little relevance to clinical medicine, a conclusion with which I strongly disagree. The examples of the productive basic science/clinical medicine interface abound. As a result of the molecular understanding of human immunodeficiency virus, new forms and combinations of therapy have changed AIDS in industrial countries from "a death sentence to a chronic disease," saving millions of lives (3). Molecular dissection of cancer-signaling pathways has produced effective new agents for the treatment of lung cancer (reviewed in Reference 4). Gene expression profiles and bioinformatics (the application of computational sciences to biology and the genome) are redefining the classification of malignancies on the basis of molecular signatures that will revolutionize diagnosis, prognosis, and choice of treatment for many cancers including lung cancer (5, 6). New diagnostics are being applied to tuberculosis (7), and our understanding of cystic fibrosis and new approaches to therapy derive directly from cloning the cystic fibrosis gene (reviewed in Reference 8). There have been new basic science–driven insights into the pathogenesis and treatment of pulmonary hypertension (9, 10) and the pathogenesis of emphysema (11). The list is long and growing. The future of personalized pharmacogenomics and of defining genetic susceptibility to disease promises a true revolution in how medicine will be practiced. I believe that the problem we have is not lack of basic science relevance; rather, it is lack of communication. Communication and cross-fertilization between clinical and basic science constituencies within our organization are not occurring in an effective fashion. The American Thoracic Society is a broad-based organization that has as its mission a commitment "to the prevention and treatment of respiratory disease through research, education, patient care and advocacy." The American Thoracic Society accomplishes this, in part, through its journals, Red and Blue, both of which are the premier pulmonary journals in the world. The Red Journal is not primarily aimed at clinicians, it is a basic science journal, but its potential relevance to clinical medicine has clearly not been appreciated nor has it been well communicated within our society. An equally disturbing message comes from questions about the annual meeting, which is highly valued by all members who responded to the survey. Virtually everyone, clinician and researcher, feels that the annual meeting is very valuable or extremely valuable to them. Yet, the majority of clinicians have attended two or fewer annual meetings, and 13% attended no meetings in the past 5 years. In contrast, 88% of researchers attended three or more of the last five annual meetings. The annual meeting has the panache and the reputation, but we may have vastly overestimated its true appeal and educational value to clinicians in our society. So how do we speak to the concerns about communication between clinicians and basic scientists that Dr. Macklem has raised? I believe that he has already taken the first step; he has recognized the problem and has challenged us, as an organization, to respond. We clearly need to begin a dialog at all levels of our society about communicating with and educating one another. We need to reexamine the educational goals of each of our journals and think of ways whereby cross-fertilization can be fostered. A simple step would be to publish the table of contents for the Blue Journal in the Red Journal and vice versa. Pithy summaries of selected articles could be published in a "This month in the other Journal" format. We should be writing short, well illustrated synopses of clinically important basic science articles relevant to lung diseases that appear in our and other journals. In addition, we need to consider inserting clinically oriented presentations that focus on the application of basic science to clinical medicine into thematic sessions at our annual meeting. Indeed, we might consider clinically oriented courses on basic science relevance to medicine at both annual and regional meetings. Perhaps this will attract more clinicians to our annual meeting. There are likely many other small and large changes we could discuss that deal with the potential "divorce" of modern biology and clinical medicine that concerns Dr Macklem. It is important to realize, however, that we are not the only society facing this problem; all of organized medicine must deal with it. Clinicians will not be able to optimally apply scientific advances if they do not understand them, and scientists will not understand clinical needs and concerns if they do not talk to clinicians. To change this requires efforts on both sides. In a recent supplement of Nature, "The Double Helix—50 Years," celebrating the anniversary of Watson and Crick's Nobel prize–winning paper on the structure of DNA, John Bell of Oxford University discusses "The double helix in clinical practice" (12). He notes that as medicine becomes more focused on molecular and genetic mechanisms of disease, we will have to redesign how we train medical students and must also face the challenge of educating a generation of clinicians to "apply the knowledge and tools bequeathed to us by the double helix." It is time that we acknowledge the real problem, rather than blaming and criticizing one another, and begin the dialog that can move the American Thoracic Society into a leadership role in maximizing the application of basic science to clinical medicine. The alternative is to meet Paul Newman's fate in the 1967 movie classic Cool Hand Luke, after he mocks the prison warden by repeating the warden's and the movie's most famous line, "What we've got here is a failure to communicate." Acknowledgments The author thanks Mary Williams and David Center for their comments and suggestions. FOOTNOTES Conflict of Interest Statement: J.S.B. has no declared conflict of interest. Received in original form May 5, 2003; accepted in final form May 14, 2003 REFERENCES
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